RESEARCH ARTICLE

Middle Ear Barotrauma in Student Pilots

Jung Heob Sohn; Kyoung Rai Cho

INTRODUCTION: The present study reports the clinical features of middle ear barotrauma in student pilots in the Republic of Korea Air
Force.
METHODS: The authors reviewed medical records of student pilots with barotrauma. The grade of barotrauma was assigned using
Teed’s classification. This study included nasal symptoms, endoscopic findings of the nasal cavity, and clinical course
Delivered
(duration, recurrence). by Ingenta
The relationship to: University
between middle earof Californiaand
barotrauma San
theDiego
nasal airway was also evaluated.
IP: 46.148.112.122 On: Mon, 22 May 2017 19:55:44
RESULTS: There were 57 cases in 51 pilots included. There were 49 cases (86.0%) that showed unilateral disease and 4 subjects
experienced relapse. Two subjects (3.9%) had chronic rhinosinusitis and four subjects (7.8%) had allergic rhinitis. Ear
fullness was reported in all cases, while hearing loss and persistent ear pain were reported in 3 cases (5.3%) and 19 cases
(33.3%), respectively. Stuffy nose (26 cases, 45.6%) and rhinorrhea (24 cases, 42.1%) were relatively common. Most cases
were Grade 0 (23 cases, 40.3%) or Grade III (27 cases, 47.4%) according to Teed’s classification. Septal deviation was
observed in 12 cases (21.0%), while turbinate hypertrophy was seen in 53 cases (93.0%) and increased nasal discharge in
33 cases (57.9%). The grade of barotrauma varied significantly according to the severity of turbinate hypertrophy and
nasal discharge. The mean duration of disease was 6.8 d.
DISCUSSION: Nasal symptoms and endoscopic findings showed some association with the grade and duration of barotrauma. Most
cases resolved within a week; however, barotrauma showed persistence or relapse in some cases.
KEYWORDS: barotrauma, middle ear, aerospace medicine, nasal cavity.

Sohn JH, Cho KR. Middle ear barotrauma in student pilots. Aerosp Med Hum Perform. 2017; 88(4):406–412.

M
Copyright: Aerospace Medical Association
iddle ear barotrauma is an inflammatory change of student pilots in the course may be at increased risk of middle
the tympanic membrane and middle ear cavity from ear barotrauma. In addition, student pilots are still learning
pressure discrepancies between the middle ear cavity active pressurization maneuvers, so they often perform an
and ambient air, which may occur during aviation, diving, or incorrect or delayed Valsalva maneuver. Prevention and man-
hyperbaric oxygen therapy.12,14 Eustachian tube dysfunction is agement of middle ear barotrauma is important for student
the most common etiology of middle ear barotrauma,10 and pilots because a long period of grounding due to persistent ear
upper airway diseases, including rhinosinusitis, allergic rhini- symptoms may steepen the learning curve in affected student
tis, septal deviation and adeno-tonsillar hypertrophy, are pilots.
known to increase nasal airway resistance.4,15 Several studies Our literature review revealed no other reports on the clini-
have reported that such nasal pathologies might be risk factors cal features of middle ear barotrauma in student pilots. Herein,
for Eustachian tube dysfunction.9,20,25 Therefore, the nasal air- the authors report the clinical course of middle ear barotrauma
way may influence the pathophysiology of middle ear baro- in student pilots in the Republic of Korea Air Force. The
trauma. The reported prevalence of middle ear barotrauma
after flight varies from 2 to 17%;22 Morgagni et al. reported that From the Department of Otorhinolaryngology - Head and Neck Surgery, Sanggye Paik
Hospital, College of Medicine, Inje University, Seoul, Korea.
the incidence of middle ear barotrauma in trained aircrews was This manuscript was received for review in May 2016. It was accepted for publication in
2.4%.15 December 2016.
KT-1 (Korea Aerospace Industries, Sacheon, Korea), a single- Address correspondence to: Kyoung Rai Cho, M.D., Ph.D., Department of Otorhinolar-
yngology - Head and Neck Surgery, Sanggye Paik Hospital, College of Medicine, Inje
engine basic training aircraft, is used for intermediate flight University, 1342 Dongil-ro, Nowon-gu, Seoul, Korea 01757; entr1@naver.com.
training programs in the Republic of Korea Air Force. This Reprint & Copyright © by the Aerospace Medical Association, Alexandria, VA.
model has no pressurization system in the cabin; therefore, DOI: https://doi.org/10.3357/AMHP.4666.2017

406  Aerospace Medicine and Human Performance  Vol. 88, No. 4  April 2017
 BAROTITIS IN STUDENT PILOTS—Sohn & Cho

relationship between middle ear barotrauma and the nasal con- Wolf Medical Instr.) and the presence of septal deviation (right/
ditions of each subject, including subjective symptoms such as left side; none), hypertrophy of the inferior turbinate (0, rigid
stuffy nose, rhinorrhea, cough, sputum, throat pain and sneez- endoscope can pass without any resistance and middle turbi-
ing, and objective nasal endoscopic findings was also estimated nate is visible; 1, only the anterior border of the middle turbi-
in the present study. nate can be seen; 2, it is impossible to advance the rigid
endoscope through the nasal cavity and no part of the middle
turbinate is visible), and the appearance of nasal discharge (0,
METHODS none; 1, scanty and mucous; 2, large amount and very thick; 3,
mucopurulent) were appraised. In addition, a medical history
Subjects of allergic rhinitis and recurrent rhinosinusitis was also taken.
This was a retrospective observational study of middle ear baro- Symptomatic treatment was given to each subject during ill-
trauma in student pilots from July 2009 to August 2010. Pilots ness. Acetaminophen 500 mg and pseudoephedrine 60 mg
who experienced ear fullness or ear pain during flight and vis- twice daily were administered orally in accordance with symp-
ited the aerospace medical corps otolaryngology clinic in the toms. Daily surveillance was applied and temporary flying
flight training wing were enrolled. After obtaining approval restrictions were imposed on all subjects until middle ear baro-
from the Institutional Ethics Committee, clinical data of the trauma improved. Improvement was defined as resolution of
subjects were reviewed in this study. symptoms and normalization of the tympanic membrane (nor-
Prior to the flight-training program, all student pilots were mal transparency of the tympanic membrane without any effu-
instructed to have their eardrum examined by an otolaryngolo- sion or perforation). After improvement, an additional 2-wk
gist and to have their hearing ability checked through pure tone monitoring period was enacted to identify any recurrence after
audiometry. Medical records, Delivered
including the presenceto:
by Ingenta of University
ear, flights
of were resumed.
California SanThe duration of illness was designated as
Diego
IP: 46.148.112.122 On: Mon, 22 May 2017 19:55:44
nose, and throat (ENT) disease and history of ear and nasal sur- the period from diagnosis to the time of improvement of mid-
gery, were also reviewed. Individuals who were found to have dle ear barotrauma. Subjects who were lost to follow-up were
ongoing morbidity that could interrupt flight missions were eventually excluded from the present study.
dropped from the program. Therefore, subjects in the present
study were generally healthy and had no evidence of permanent Statistical Analysis
Eustachian tube dysfunction. Training aircraft climbed up to The Cochran-Armitage trend test was used to investigate rela-
5486.4 m (18,000 ft) altitude during flight training and flight tionships between the grades of eardrum trauma, combined
missions usually took place between 4267.2 m (14,000 ft) and nasal symptoms, objective findings of the nasal cavity, and
4876.8 (16,000 ft) altitude. If trainees experienced any discom- duration of illness in cases of middle ear barotrauma. All statis-
fort during flight training, they were instructed to suspend the tical analyses were performed using R package version 3.2.4
mission and reduce the flight altitude. In the case that their (http://www.r-project.org). The level of significance was set at
symptoms continued or worsened even after landing, student P , 0.05.
pilots were told to visit the clinic in the aerospace medical corps.

Procedure RESULTS
Copyright: Aerospace Medical Association
Subjects complaining of ear symptoms (ear fullness, ear pain,
tinnitus, otorrhea, or hearing loss) had their eardrums evalu- There were 57 cases from 51 pilots (47 men, 4 women) even-
ated for middle ear barotrauma with a 0°, 2.7-mm rigid endo- tually eligible for this study. Two cases (3.4%) were lost to
scope (Richard Wolf Medical Instr., Vernon Hills, IL) by follow-up, so they were excluded. The mean age of the subjects
an otolaryngologist who was also a certified flight surgeon. was 24 yr (23 to 26 yr). There were 31 cases (54.4%) that affected
According to the objective findings of the eardrum, the severity the right ear and 18 cases (31.6%) that affected the left ear;
of middle ear barotrauma was categorized using Teed’s classifi- 8 cases (14.0%) were bilateral. Four student pilots (three men,
cation:23 Grade 0 (no sign of barotrauma), Grade I (retraction one woman) had recurrent middle ear barotrauma (Table I).
of the tympanic membrane with partial redness in Shrapnell’s These cases exhibited a 2-wk or longer disease-free period
membrane and along the manubrium), Grade II (retraction of prior to each onset; therefore, each of these 10 incidents (17.5%)
the tympanic membrane with total hyperemia), Grade III was considered a discrete case. Two pilots (3.9%) had a previ-
(hemo-tympanum with or without air fluid level in the middle ous history of chronic rhinosinusitis and four subjects (7.8%)
ear), and Grade IV (rupture of the tympanic membrane). In had been diagnosed with allergic rhinitis.
bilateral cases, the grade of middle ear barotrauma was deter- All pilots complained of persistent ear fullness (100.0%).
mined by the findings of the more serious side. Hearing loss was reported in 3 cases (5.3%) and persistent ear
Combined nasal symptoms (stuffy nose, rhinorrhea, cough, pain was observed in 19 cases (33.3%). No subject had otorrhea
sputum, throat pain, and sneezing) during flights were also or tinnitus. Information on combined nasal symptoms for all
assessed and the degree of discomfort was rated on a score from cases is shown in Fig. 1. A stuffy nose was reported in 26 cases
0 to 2 (0, none; 1, mild; 2, moderate to severe). The nasal cavity (45.6%) and rhinorrhea in 24 cases (42.1%). Sputum was dem-
was inspected with a 30°, 4.0-mm rigid endoscope (Richard onstrated in 13 cases (22.8%) and cough in 11 cases (19.3%).

Aerospace Medicine and Human Performance  Vol. 88, No. 4  April 2017   407
BAROTITIS IN STUDENT PILOTS—Sohn & Cho

Table I. Clinical Characteristics of Four Subjects with Recurrent Middle Ear Barotrauma.
EAR SYMPTOMS
SEX AGE PAST HISTORY INTERVAL (DAYS) GRADE DURATION (DAYS) HEARING LOSS EAR FULLNESS EAR PAIN
1 F 23 None 0 III 22 + +
37 III 2 +
2 M 25 None 0 III 5 +
36 III 6 + +
71 I 35 + +
3 M 24 Chronic rhino-sinusitis 0 III 14 + +
65 0 3 + +
4 M 24 Allergic rhinitis 0 0 2 +
19 III 9 +
65 III 3 +
Interval (days) means the duration of time between the onset of prior and present episodes of middle ear barotrauma in each subject.

Nine subjects (15.8%) complained of throat pain and seven either stuffy nose (T 5 1.996, df 5 1, P 5 0.158) or rhinorrhea
cases (12.3%) reported sneezing. (T 5 2.640, df 5 1, P 5 0.104). The presence of septal deviation
Using Teed’s classification, 23 cases (40.3%) were classified was not significantly associated with grade (T 5 1.824, df 5 1,
as Grade 0 and 27 (47.4%) as Grade III. Five subjects (8.8%) P 5 0.177). Meanwhile, the severity of turbinate hypertrophy
were Grade I and two (3.5%) with eardrum rupture were classi- (T 5 5.044, df 5 1, P 5 0.025) and nasal discharge (T 5 8.401,
fied as Grade IV. Endoscopic findings of the nasal cavity are df 5 1, P 5 0.004) demonstrated a relevant difference in accor-
displayed in Fig. 2. A deviated nasal septum
Delivered bywas foundto:
Ingenta in University
12 danceofwith the gradeSan
California of the affected eardrum.
Diego
IP: 46.148.112.122
cases (21.0%), 10 cases (17.5%) had right-sided deviation, and 2 On: Mon, 22 May 2017 19:55:44
The mean duration of illness (the time from diagnosis to
cases (3.5%) had left-sided deviation. Hypertrophy of the infe- improvement of middle ear barotraumas) was 6.8 d (1–60 d,
rior turbinate was observed in most cases (53 cases, 93.0%). median: 4 d). Without any recurrence, 16 cases (28.1%)
Among the 53 cases with hypertrophy of the inferior turbinate, improved within 2 d, while 43 cases (75.4%) resolved within
the score of turbinate hypertrophy was defined as “1” in 21 a week (Fig. 3). The duration of illness was categorized into
cases (36.9%), while the score was defined as “2” in 32 cases four groups: group 1 (subjects who were improved within
(56.1%). Increased nasal discharge was seen in 33 cases (57.9%); 2 d), group 2 (subjects who were improved within 4 d),
there were 22 cases (38.6%) with mucous nasal discharge and group 3 (subjects who were improved within 7 d), and group
10 cases (17.5%) with a large amount of very thick nasal secre- 4 (disease duration was more than 7 d). Then the categorized
tion. One pilot (1.8%) had acute bacterial rhinosinusitis with data of the disease duration was analyzed with the grade of
mucopurulent nasal discharge. She was prescribed oral antibi- middle ear barotrauma. There was a tendency to take more
otics (amoxicillin-clavulanate 625 mg, three times daily for 7 d) time to recover from middle ear barotrauma depending on
and improved within a week without recurrence. the grade (T 5 11.503, df 5 1, P 5 0.001). The association
The distribution of nasal symptom severity and endoscopic between duration and grade of middle ear barotrauma is
findings according to the grade of middle ear barotrauma
Copyright: Aerospace shown
Medical Fig. 4.
in Association
are shown in Table II and Table III. Pilots tended to display One case that took 60 d to completely resolve demonstrated
more severe stuffy nose and rhinorrhea depending on the baro- bilateral middle ear trauma with a perforated right tympanic
traumas grade; however, there was no statistical significance for membrane (Grade IV). The left ear drum was completely turbid
with an amber-colored effusion and retraction. Nasal endos-
copy showed moderate to severe hypertrophy of the inferior
turbinate and a large amount of thick nasal secretion. The pilot
had no history of other episodes of chronic rhinosinusitis or
allergic rhinitis. It initially took 16 d for improvement in subjec-
tive symptoms and eardrum findings; however, he reported
recurrent ear pain and ear fullness after resuming flight. The left
tympanic membrane was retracted and fully turbid with effu-
sion. At first, there was no evidence of recurrent barotrauma in
the right eardrum; however, during follow-up, middle ear effu-
sion was present on the right side and retraction of both ear-
drums had progressed to the promontory of the middle ear.
Methylprednisolone 24 mg daily was administered orally for
7 d and the middle ear effusion disappeared after 15 d. Both the
pilot’s symptoms and objective findings were entirely resolved
Fig. 1. Combined nasal symptoms of affected student pilots, including the 2 mo after initial onset and there were no relapses. Due to the
number and percentage of cases according to the severity of nasal symptoms. long duration of flight restriction, he failed his training course;

408  Aerospace Medicine and Human Performance  Vol. 88, No. 4  April 2017
 BAROTITIS IN STUDENT PILOTS—Sohn & Cho

middle ear barotrauma, which can occur after changes in baro-

metric pressure.2 The reported prevalence of middle ear baro-
trauma varies,1,5,16 but it might be underestimated in Air Force
pilots, who tend to avoid reporting discomfort in order to avoid
interference with their flight training and career. This study was
performed based on clinical features of middle ear barotrauma
in student pilots, who were less likely to drop out of follow-up.
Therefore, the authors expected to obtain useful information
about the management of middle ear barotrauma in aircrews.
Middle ear barotrauma can occur under conditions that
interrupt the function of the Eustachian tube or in cases in
which the velocity of pressure change exceeds tube compe-
tency.6 The Eustachian tube, which controls middle ear pres-
sure, acts as a one-way valve, with the proximal cartilaginous
portion of the tube collapsing and opening spontaneously when
Fig. 2. Distribution of the nasal endoscopic findings for all subjects. DSN: devia- middle ear pressure surpasses ambient pressure.11,12 Therefore,
tion of nasal septum, ITH: hypertrophy of inferior turbinate. For DSN, “0” indicates active pressurization maneuvers such as yawning, swallowing,
the absence of septal deviation. Left-sided deviation was designated as “1” and or the Valsalva maneuver are required to open the tube for
right-sided deviation as “2.” The ITH score (0, middle turbinate is fully visible; 1,
pilots during landing or other changes in altitude.8,17,19 An
middle turbinate can be seen partially; 2, no part of the middle turbinate is visible)
and nasal discharge (0, none; 1, scanty and mucous; 2, a large amount or very impaired ability to equalize middle ear pressure can increase
Delivered
thick; 3, mucopurulent) were graded according by Ingenta
to the nasal endoscopyto: the pressure
University
findings. differential
of California so that mucosal congestion and hemor-
San Diego
IP: 46.148.112.122 On: Mon,rhagic 22 May 2017 19:55:44
transudates may occur in the middle ear cavity 12.
however, he eventually passed the following course. Another In a broader sense, otitis media encompasses middle ear
case, which required 35 d for full recovery, was unilateral. The left barotrauma. Both exhibit Eustachian tube dysfunction as a pri-
eardrum was retracted and touched the malleus and no effusion mary cause and display pathological findings of the middle ear
was seen (Grade I). Nasal endoscopic findings exhibited devia- cavity. Risk factors for otitis media include upper respiratory
tion of the nasal septum to the right side, inferior turbinate tract diseases such as allergic rhinitis, rhinosinusitis, recurrent
hypertrophy with a score of 2, and very thick nasal discharge. The infections, septal deviation, and chronic adenotonsillar dis-
pilot did not have a history of chronic rhinosinusitis or allergic ease.13,18,21 The nasal airway has been reported to be an impor-
rhinitis, but reported two prior episodes of middle ear baro- tant factor in the etiology of otitis media.3,7,24 In addition,
trauma that improved within a week. His eardrum retraction Morgagni et al. showed that a previous history of ENT disease
lasted over a month and, similar to the previous case, he also ini- may be a predictor of delayed ear pain and ENT abnormalities
tially failed the flight course, but passed the following course. predict acute middle ear barotrauma.15 Igarashi et al. also dem-
onstrated that upper respiratory tract infections or mucosal
congestion could be predisposing factors for middle ear baro-
DISCUSSION Copyright: Aerospace Medical trauma.9Association
Nevertheless, these studies did not provide detailed
information regarding specific ENT diseases.
Ear pain during flight is often regarded as a natural physiologi- In the present study, concomitant nasal symptoms and
cal phenomenon. However, cases with eardrum pathology or nasal endoscopic findings were found to be associated with
persistent ear pain or fullness after flight are often diagnosed as clinical characteristics of middle ear barotrauma. Among

Table II. Distribution of Severity of Nasal Symptoms in Accordance with the Grade of Middle Ear Barotrauma.
NASAL SYMPTOMS [N (%)]
GRADE NUMBER OF CASES SEVERITY STUFFY NOSE RHINORRHEA COUGH SPUTUM THROAT PAIN SNEEZE
0 23 0 14 (60.9%) 16 (69.6%) 21 (91.2%) 20 (87.0%) 18 (78.3%) 20 (87.0%)
1 6 (26.1%) 6 (26.1%) 1 (4.4%) 3 (13.0%) 3 (13.0%) 2 (8.6%)
2 3 (13.0%) 1 (4.3%) 1 (4.4%) 0 2 (8.7%) 1 (4.4%)
I 5 0 2 (40.0%) 1 (20.0%) 2 (40.0%) 4 (80.0%) 5 (100.0%) 3 (60.0%)
1 0 4 (80.0%) 2 (40.0%) 1 (20.0%) 0 2 (40.0%)
2 3 (60.0%) 0 1 (20.0%) 0 0 0
III 27 0 15 (55.6%) 16 (59.3%) 22 (81.5%) 19 (70.4%) 24 (88.9%) 25 (92.6%)
1 3 (11.1%) 6 (22.2%) 3 (11.1%) 5 (18.5%) 3 (11.1%) 0
2 9 (33.3%) 5 (18.5%) 2 (7.4%) 3 (11.1%) 0 2 (7.4%)
IV 2 0 0 0 1 (50.0%) 1 (50.0%) 1 (50.0%) 2 (100.0%)
1 0 1 (50.0%) 1 (50.0%) 1 (50.0%) 1 (50.0%) 0
2 2 (100.0%) 1 (50.0%) 0 0 0 0
Trend Test P 5 0.158 P 5 0.104 P 5 0.513 P 5 0.063 P 5 0.338 P 5 0.712

Aerospace Medicine and Human Performance  Vol. 88, No. 4  April 2017   409
BAROTITIS IN STUDENT PILOTS—Sohn & Cho

Table III. Distribution of Severity of Nasal Endoscopic Findings in Accordance with the Grade of Middle Ear Barotrauma.
NASAL ENDOSCOPY
NASAL ENDOSCOPY [N (%)] [N (%)]
HYPERTROPHY OF DEVIATION OF NASAL
GRADE NUMBER OF CASES SEVERITY TURBINATE (0-2) NASAL DISCHARGE (0-3) STATUS SEPTUM
0 23 0 3 (13.0%) 15 (65.2%) None 21 (91.3%)
1 11 (47.8%) 7 (30.4%) R-sided 2 (8.7%)
2 9 (39.2%) 1 (4.4%)
3 0 L-sided 0
I 5 0 0 0 None 3 (60.0%)
1 2 (40.0%) 4 (80.0%) R-sided 2 (40.0%)
2 3 (60.0%) 1 (20.0%)
3 0 L-sided 0
III 27 0 1 (3.7%) 9 (33.3%) None 19 (70.4%)
1 8 (29.6%) 11 (40.8%) R-sided 6 (22.2%)
2 18 (66.7%) 6 (22.2%)
3 1 (3.7%) L-sided 2 (7.4%)
IV 2 0 0 0 None 2 (100.0%)
1 0 0 R-sided 0
2 2 (100.0%) 2 (100.0%)
3 0 L-sided 0
Trend Test P 5 0.025 P 5 0.004 P 5 0.177

Delivered by Ingenta to: University of California San Diego

nasal symptoms, stuffy nose (45.6%) IP:and
46.148.112.122
rhinorrhea (42.1%) On: Mon, 22 May
severity 2017endoscopic
of nasal 19:55:44 findings (turbinate hypertrophy
were relatively common in cases with middle ear barotrauma. and pathological nasal discharge) and the grade of middle ear
Regarding nasal endoscopic findings, most pilots demon- barotrauma was verified in the present study (P , 0.05). How-
strated hypertrophy of the inferior turbinate (93.0%) and ever, both nasal symptoms and endoscopic findings showed
almost two-thirds (57.9%) exhibited increased nasal dis- no definite relation to relapse. The prior incidence of chronic
charge, while the prevalence of combined septal deviation was rhinosinusitis (7.8%) or allergic rhinitis (3.9%) was low in this
correspondingly lower. In addition, a correlation between the study. Furthermore, only two of four allergic subjects dis-
played acute exacerbation of
allergic rhinitis, while the other
two showed no related changes
in allergic rhinitis. Acute altera-
tions of the nasal airway during
flight seem to be more strongly
related to middle ear barotrau-
Copyright: Aerospace Medical Association mas than chronic nasal disease.
The authors also described
the grade of middle ear baro-
trauma using Teed’s classifica-
tion. This classification is concise
and reflects the prognosis of
middle ear barotrauma.23 How-
ever, it does not provide suffi-
cient data about the severity of
tympanic retraction, so its use
leads to ambiguity in cases with
both retraction and redness of
the affected eardrum. Therefore,
the authors suggest a modifica-
tion of Teed’s classification as fol-
lows: Grade I (mild retraction of
the tympanic membrane with
redness) and Grade II (moder-
ate retraction of the tympanic
Fig. 3.  Histogram presenting the distribution of cases over the period of middle ear barotraumas for all subjects. Of all membrane and total hyperemia).
cases, 75% improved within a week (*). Grade 0, Grade III, and Grade IV

410  Aerospace Medicine and Human Performance  Vol. 88, No. 4  April 2017
 BAROTITIS IN STUDENT PILOTS—Sohn & Cho

In conclusion, a stuffy nose and rhinorrhea were relatively

Fig. 4. Scatterplot of duration and grade of middle ear barotrauma, indicating
a significant correlation (T 5 11.503, df 5 1, P 5 0.001).
common symptoms in generally healthy student pilots who
sustained middle ear barotrauma. Most subjects also demon-
strated abnormal nasal endoscopic findings such as turbinate
hypertrophy or pathological nasal discharge. Subjective nasal
symptoms and endoscopic findings were related to the grade
and duration of middle ear barotrauma. Questionnaires regard-
ing subjective nasal symptoms and examination with portable
nasal endoscopy may be useful for predicting middle ear baro-
trauma prior to flight training. The majority of cases of middle
ear barotrauma resolved within a week; however, some sub-
jects experienced relapse or symptom duration of even a month
or more.
ACKNOWLEDGMENTS

The authors did not receive any financial or material support for this research.
remain the same as the original classification. Further investiga-
tion of middle ear barotrauma using this modified Teed’s clas- Authors and affiliation: Jung Heob Sohn, M.D., and Kyoung Rai Cho, Ph.D.,
Department of Otorhinolaryngology – Head and Neck Surgery, Sanggye Paik
sification is needed. Hospital, College of Medicine, Inje University, Seoul, Korea.
The duration of middle earDelivered
barotrauma bymight be consid-
Ingenta to: University of California San Diego
ered the most important concernIP: for 46.148.112.122
student pilots. TheOn:lon-Mon, 22 May 2017 19:55:44
REFERENCES
ger their flight training was interrupted, the worse their
achievement was in training missions. Accordingly, student 1. al-Wedyan IA, Shahin BH, Abu Ghosh HM, al-Aqqad SS, al-Qura’an
pilots with a long period of grounding might drop out of MS. Physiological training in Jordan. Aviat Space Environ Med. 1996;
flight-training programs. The mean disease duration was 67(9):882–884.
6.8 d. Fortunately, 43 cases (75.4%) improved within a week, 2. Carlson S, Jones J, Brown M, Hess C. Prevention of hyperbaric-associated
middle ear barotrauma. Ann Emerg Med. 1992; 21(12):1468–1471.
while 49 cases (86.0%) resolved within 10 d without sequelae;
3. Cingi C, Altin F, Cakli H, Entok E, Gurbuz K, Cingi E. Scintigraphic
16 cases (28.1%) were completely resolved within 2 d. The evaluation of nasal mucociliary activity in unilateral chronic otitis media.
cases that improved within 2 d showed less severe stuffy J Laryngol Otol. 2005; 119(6):443–447.
nose (T 5 4.615, df 5 1, P 5 0.032) and rhinorrhea (T 5 4. Davenport NA. Predictors of barotrauma events in a Navy altitude
4.1078, df 5 1, P 5 0.043) in comparison with cases lasting chamber. Aviat Space Environ Med. 1997; 68(1):61–65.
5. DeGroot DW, Devine JA, Fulco CS. Incidence of adverse reactions from
a week or more. In addition, hypertrophy of the inferior
23,000 exposures to simulated terrestrial altitudes up to 8900 m. Aviat
turbinate (T 5 21.066, df 5 1, P , 0.001) and nasal dis- Space Environ Med. 2003; 74(9):994–997.
charge (T 5 12.056, df 5 1, P 5 0.001) on nasal endoscopy 6. Flisberg K, Ingelstedt S, Ortegren U. The valve and “locking” mechanisms
were also less severe in the group with shorter Aerospace
Copyright: symptom Medical of theAssociation
Eustachian tube. Acta Otolaryngol Suppl. 1963; 182:57–68.
duration. Additional attempts to identify factors contribut- 7. Güçlü O, Sahin EM, Tekin K, Dereköy FS. Evaluation of nasal airways by
objective methods in chronic otitis media. Eur Arch Otorhinolaryngol.
ing to the duration of middle ear barotrauma are necessary
2013; 270(4):1263–1266.
in well-designed, larger-scale studies. 8. Handzel O, Poe D, Marchbanks RJ. Synchronous endoscopy and
The major limitation of the present report is that it did not sonotubometry of the Eustachian tube: a pilot study. Otol Neurotol. 2012;
include otology tests such as pure tone audiometry or tympa- 33(2):184–191.
nometry. Second, no further objective method to demonstrate 9. Igarashi Y, Watanabe Y, Mizukoshi K. Middle ear barotrauma associated
with hyperbaric oxygenation treatment. Acta Otolaryngol Suppl. 1993;
nasal resistance such as acoustic rhinometry or rhinomanom-
113(Suppl. 504):143–145.
etry was applied in this research, as these tests are difficult to 10. Kang CI, Na JW, Kim SK, Choi WC, Park MK, Lee SY. The Study on the
perform before each flight for all subjects. In addition, most Preventive Method of the Middle Ear Barotrauma Caused by Hyperbaric
aerospace medical corps in the flight wing of the Republic of Oxygen Therapy. Korean J Otolaryngol-Head Neck Surg. 2002; 45(1):22–
Korea Air Force did not possess the test equipment needed 25 [in Korean].
11. Keller AP Jr. A study of the relationship of air pressure to myringorupture.
due to budgetary restrictions and a lack of trained technicians.
Laryngoscope. 1958; 68(12):2015–2029.
Complementary studies with these parameters would provide 12. Landolfi A, Torchia F, Autore A, Ciniglio Appiani M, Morgagni F,
more information about middle ear barotrauma. Question- Ciniglio Appiani G. Acute otitic barotrauma during hypobaric chamber
naires regarding subjective nasal symptoms and examinations training: prevalence and prevention. Aviat Space Environ Med. 2009;
with portable nasal endoscopy are simple and easy to perform 80(12):1059–1062.
13. Licameli GR. The Eustachian tube. Update on anatomy, development, and
before flights. Additional prospective cohort studies are required
function. Otolaryngol Clin North Am. 2002; 35(4):803–809.
to evaluate the combination of subjective nasal symptoms and 14. Mitchell-Innes A, Young E, Vasiljevic A, Rashid M. Air travellers’ aware­
objective nasal endoscopic findings as predictors for middle ness of the preventability of otic barotrauma. J Laryngol Otol. 2014; 128(6):
ear barotrauma. 494–498.

Aerospace Medicine and Human Performance  Vol. 88, No. 4  April 2017   411
BAROTITIS IN STUDENT PILOTS—Sohn & Cho

15. Morgagni F, Autore A, Landolfi A, Ciniglio Appiani M, Ciniglio Appiani
G. Predictors of ear barotrauma in aircrews exposed to simulated high
altitude. Aviat Space Environ Med. 2012; 83(6):594–597.
16. Ohrui N, Takeuchi A, Tong A, Ohuchi M, Iwata M, et al. Physiological
incidents during 39 years of hypobaric chamber training in Japan. Aviat
Space Environ Med. 2002; 73(4):395–398.
17. Poe DS, Pyykko I, Valtonen H, Silvola J. Analysis of Eustachian tube
dysfunction by video endoscopy. Am J Otol. 2000; 21:602–607.
18. Rosenkvist L, Klokker M, Katholm M. Upper repiratory infections and
barotraumas in commercial pilots: a retrospective survey. Aviat Space
Environ Med. 2008; 79(10):960–963.
19. Sade J, Ar A. Middle ear and auditory tube: middle ear clearance, gas
exchange, and pressure regulation. Otolaryngol Head Neck Surg. 1997;
116(4):499–524.
20. Scarano E, Fetoni AR, Picciotti P, Cadoni G, Galli J, Paludetti G. Can
chronic nasal obstruction cause dysfunction of the paratubal muscles
and otitis media? An experimental study in developing wistar rats. Acta
Otolaryngol. 2003; 123(2):288–291.
21. Sismanis A. Otitis media: the pathogenesis approach. Assessment and
treatment of associated upper respiratory tract pathology. Otolaryngol
Clin North Am. 1991; 24(4):947–955.
22. Stangerup SE, Klokker M, Vesterhauge S, Jayaraj S, Rea P, Harcourt J. Point
prevalence of barotitis and its prevention and treatment with nasal balloon
inflation: a prospective, controlled study. Otol Neurotol. 2004; 25(2):89–94.
23. Teed RW. Factors producing obstruction of the auditory tube in
submarine personnel. U S Nav Med Bull. 1944; 42:293–306.
24. Watson C. Chronic otitis media: the significance of nasal obstruction.
Clin Otolaryngol Allied Sci. 1990; 15(5):435–438.
25. Yilmaz MS, Guven M, Buyukarslan DG, Kaymaz R, Erkorkmaz U. Do
silicone nasal septal splints with integral airway reduce postoperative
Eustachian tube dysfunction? Otolaryngol Head Neck Surg. 2012;
146(1):141–145.

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